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When the New York Times referred to Mary Pappas as "a sort of folk hero to nurses across the country" in an April 28 article, it was a rare recognition of the role school nurses play. Pappas is the school nurse at St. Francis Preparatory School in New York City, where the first U.S. cases of influenza A (H1N1)—the swine flu—were identified in April. She was the first link in a chain that led to the Centers for Disease Control and Prevention (CDC); within days of her April 23 call alerting public health authorities of the symptoms she saw in St. Francis students, the school was closed and the world was on alert for a pandemic.

"It's been a turning point in my career to put school nurses on the map," Pappas told AJN in early May, after her students had returned to school and the media attention had waned. "I wanted to promote school nursing, not promote me personally. I just pushed it over the edge."

What Pappas "pushed over the edge" was an awareness of the crucial yet nearly invisible role, not to mention the acute shortage, of nurses in schools. There are more than 45,000 school nurses in the United States—one nurse for every 1,155 students. That's a "dangerous" ratio, according to the American Federation of Teachers, and one far short of that recommended by the National Association of School Nurses (NASN), which is one nurse for every 750 well students (that is, those without chronic illness).

How will the nursing shortage affect schools, especially since the CDC's May 5 reversal of its mandate that schools close for suspected or confirmed H1N1 cases? The Albuquerque, New Mexico, public school system, for example, has 18 elementary schools with only a half-time nurse in each. They've been supplementing nursing staff with full-time "health technicians," as well as with a healthy dose of common sense, said Cindy Greenberg, manager of nursing services. The schools have been ensuring that all bathrooms have running water and plenty of soap, and the nurses have instructed staff and students in handwashing techniques. (That protocol had been in place from a recent flu season when there'd been a shortage of vaccines.)

Still, Greenberg spoke to the health technicians' limits. "They have an associate's degree and are trained in first aid and [cardiopulmonary resuscitation]," she said. "But they cannot assess." If there's a suspected H1N1 case, they're to call one of the school system's nurses, who will respond as soon as possible.

That strength of nurses—their assessment skills—has been much on the mind of Amy Garcia, NASN executive director. Now, more than ever, she said, "the assessment skills of the school RN cannot be replaced. The lessons learned from the 1918 flu is that the sooner you start limiting contacts, particularly among children, the sooner the epidemic can be contained."

It remains to be seen whether the current H1N1 outbreaks will reach a pandemic level (by mid-May the World Health Organization declared that "a pandemic is imminent"). Garcia said that in 1918 the influenza outbreaks began in the spring "and came back with a ferocity in the fall. This is a time for us to review our procedures and make sure we have the appropriate systems in place to care for those we're charged with caring for."